The accompanying editorial by Biccard and Green-Thompson describes how, in most low and middle-income countries, the demand for care far outstrips the capacity to provide it. There seems to be a global maldistribution of anaesthetic and surgical expertise, and part of the solution could be socially accountable education of future practitioners. They argue this should produce healthcare graduates who are responsive to the social needs of the local environment. Standards of care can be concurrently formed through partnerships and innovations, such as the Lifebox initiative (more about that here). Motivated learners can then be identified and supported through fellowships and emerge as socially responsive healthcare providers, able to address the limitations of a resource-limited environment. Socially accountable anaesthesia is therefore less about transference of a system into a country and more about supporting an existing system to thrive and become sustainable, and the trainee fellowship programme in Uganda is a remarkable example of this.

Clinical decision-making is a strong theme throughout this month’s Anaesthesia. Using the example of cricket (more about the reason for this later!) ‘the corridor of uncertainty’ is an area a bowler aims to pitch their delivery so as to induce uncertainty in the batsman’s decision to play or leave, move forward or back, and defend or attack. Whether or not the correct decision was made soon becomes clear, particularly if a wrong shot, a late movement, hesitation or indecision result in a dismissal. The clinical corridor of uncertainty is arguably no different. We are pitched complex clinical problems and our job is to use knowledge, experience and ‘heuristics’ (more about that here) to make the best decisions for our patients. In anaesthesia and critical care, we soon find out whether or not we made the right choice too! This month’s edition is packed full of clinical content to help reduce uncertainty, guide decision-making and improve care for patients.

Continuing with the cricket theme (there was a reason we chose it!), Tavare and Pandit present their much anticipated statistically speaking article, ‘When rain stops play: a ‘Duckworth-Lewis method’ for surgical operating list productivity?’ Is it possible to compare the productivity of, for example, a cardiac theatre with two scheduled cases and a urology theatre undertaking ten operations in the same time period? It turns out we can use a well-known statistical method whose usual function is to calculate the target score for a team batting second in a limited overs match that is interrupted, typically by rain (Figure 1). In fact, the curves for operating theatre productivity are similar to the Duckworth-Lewis cricket model and the same principles seem to apply. Is working in the NHS the same as batting in the rain? The answer is educational, philosophical and entertaining, as is the article as a whole. We really enjoyed reading this one!

Figure 1 Duckworth–Lewis performance curve relating resources (%, y-axis) to overs remaining (x-axis), as a function of wickets (isopleths). The resource % is then used to calculate the target score for the second team after an interruption.

The start of a new year isn’t usually much fun. Short days, long nights, back to work and a guilt-driven desire to visit a gym and eat salad. On the other hand, it’s nearly time for the AAGBI Winter Scientific Meeting, and we recently published our free to access supplement issue, ‘Complications’! Our Friday morning session (12th January) is all about the complications of anaesthesia and it is no coincidence the two are related. First up is Dr Alastair Glossop from Sheffield discussing respiratory complications followed by Dr Guillermo Martinez from Cambridge, who will give a much-anticipated talk about cardiovascular complications. Finally, we are delighted to have Dr Heidi Doughty, a consultant in Transfusion Medicine from the NHS Blood & Transplant service, present the complications of blood transfusion. If you are registered for #WSMLondon18 please do come along and engage with us either in person or on Twitter. If you aren’t yet registered, here is the link.

That’s all for now, but planning for the 2019 supplement ‘Pre-operative optimisation of the surgical patient’ is already well underway. We do hope you enjoy the 2018 complications supplement and that it provides ample education and stimulation whilst retaining clinical relevance to all. Please discuss and engage with the articles either through twitter or formally through our correspondence site as we are always interested to hear what you think. See you in London next week!

Finally, preparations are well underway for the AAGBI Winter Scientific Meeting in London (10th-12th January). Congratulations to all those with an accepted abstract! Our ‘How to publish a paper’ workshop (11th January, 2-4pm) is once again free to all attendees. Matt Wiles chairs the Friday morning Anaesthesia session with topics for discussion including respiratory, cardiovascular and blood transfusion associated complications. Our stand will be open throughout and we very much hope to see you there!

This month in Anaesthesia sees a welcome addition to the above in the form of a systematic review and meta-analysis of VL vs. DL use by experienced anaesthetists in patients with a known difficult airway. The authors retrieved 9 articles with a total of 1329 patients and concluded VL to be associated with greater success at the first attempt, even with an experienced DL operator (OR 0.34 [95% CI 0.18-0.66]). In addition, VL yielded fewer Cormack and Lehane grade 3 and 4 views (OR 0.04 [95% CI 0.01-0.15]) and less mucosal trauma (OR 0.16 [95% CI 0.04-0.75]). The question remains however, should VL become the standard of care for the initial approach to intubation in the context of a known difficult airway? We would very much like to hear your opinions on this one! Get in touch with us through Twitter or Facebook.

Keeping with the VL theme, Abrons et al. report an RCT of asleep VL-assisted nasotracheal intubation using either a bougie (Figure 1) or non-bougie technique. They found a significant reduction in the incidence/severity of bleeding and trauma to the nasopharynx with the bougie technique, though with no difference in first attempt and overall success rates. For those who regularly perform nasotracheal intubations, will this study change your practice? Let us know!

Figure 1 The tracheal tube (red arrow) is seen advancing over the bougie.

There is little doubt that major trauma care has significantly improved over the last three decades. This is likely due to the cumulative effect of a number of practice changes such as, but not limited to, regional trauma networks, education (though ATLS and its limitations have been discussed at length) and the implementation of systems and procedures from the military setting. In this month’s Anaesthesia, Stein et al. report retrospective observational data from University Hospital, Zürich before (2005-07) and after (2012-14) establishing several quality improvement bundles, including the implementation of a goal-directed transfusion and coagulation algorithm. They found significant reductions in the incidence of massive transfusion, administration of blood products, mortality and ICU stay (Table 1).

Table 1 Raw and adjusted differences in transfusion of allogeneic blood products and outcome between the two cohorts (2005–2007 and 2012–2014). Values are number (proportion), mean (SD) and odds ratio (95%CI)

Smith and Choi urge for cautions interpretation of these results. The main issue seems to be the retrospective manner of data collection and the resultant difficulty in determining the exact size of the effect. This begs the question, why do we persist with retrospective studies when they have clear limitations? One suggestion is that, through versatility and pragmatism, retrospective observation can force rapid advances in patient care by allowing us to form testable hypotheses, establish trends and make sense of clinical practice. As we have seen with ERAS+, comparing outcomes before and after a series of quality improvement interventions can provide powerful evidence for these practice changes. There are several retrospective observational studies this month and we will no doubt see many more in the future.

We are seeing more older adults with injuries sustained through major trauma and the results from Stein et al. support this perception. In the UK, over half of all those entered onto a recent national trauma database were over 60 years old. Griffiths and Kumar discuss the implications of this changing demographic and ask whether systems for the management of major trauma are fit for the needs of older adults? The recent ‘Trauma Audit and Research Network (TARN)’ report suggests that many improvements are required, starting with more effective ways of injury prevention in the home. The one bit of good news (and there isn’t much) is that many older patients do well and return home following a full recovery. The report and editorial are essential reading for anyone with an interest in trauma management.

Green et al. report an analysis of CLWRota data from 2.5 million anaesthetic sessions during 2015. Their aim was to look at the number of supervised sessions trainees undertook as compared with the three per week RCoA standard. The results show the majority of trainees did not achieve this, more so with increasing seniority (Figure 1). It is suggested, amongst other measures, that logbook inspection should be more frequent so that training can be tailored to individual trainee requirements.

Penfold and Carey, the Joint Chairs of the Training Committee of the RCoA, write in their accompanying editorial that although trainees may not be meeting RCoA supervision standards, the overall impact of this may be difficult to quantify. Moreover, there are many barriers for Schools in their quest to meet these standards. Keeping with the training theme, England and Jenkins argue that clinical time is the most important aspect of a training programme and that it should be protected. They call for efficiency in the delivery of training outside the clinical environment and for trainers to provide this without reducing clinical time. What do you think about supervision and training time? Send us a letter through our correspondence website, or tweet us!

We continue to invite authors to submit narrative as well as systematic reviews to Anaesthesia, as we believe both evidence and opinion have their place in modern science and medicine. This month, Trend et al. present a narrative review of aerosolised drug therapy in children receiving respiratory support. It seems that we know less about the use of such drugs in these circumstances, and this review provides guidance as to when and how the inhaled route may be of value for such patients (Table 2).

Table 2 The clinical use of inhaled medications in children within speciﬁc therapeutic contexts.

Elsewhere, Bagchi et al. examine the association between the mode of perioperative ventilation and postoperative pulmonary complications (POPCs) in 109,360 patients (this has already generated a lot of interest on Twitter!). They found pressure-controlled ventilation to be associated with more POPCs, possibly due to higher driving pressures, higher tidal volumes and low or no PEEP. Heesen et al. report their results from a systematic review of epidural volume extension (EVE) by saline injection, and its effect on the efficacy and safety of intrathecal local anaesthetics. They found inadequate evidence in general, although a shorter motor block recovery time may result. Onodi et al. examine the difference between arterial and end-tidal carbon dioxide in 799 children undergoing mechanical ventilation during general anaesthesia. They conclude end-tidal monitoring of carbon dioxide may lead to an unrecognised hypocarbia.

There is much more in this month’s edition including a case series of apnoeic oxygenation for laryngeal surgery, an evaluation of various epidural drug mixes for labour analgesia and a comparison of gastric emptying for soluble solid meals and clear fluids matched for volume and energy content.

Finally, we were delighted to reveal the Top 10 Papers of 2016 at the recent Annual Congress meeting in Liverpool. You can find all these high-impact articles online in one convenient location. Our ‘How to publish a paper’ workshop continues to be well attended (Figure 2), and we look forward to seeing the abundance of ideas, enthusiasm and creativity transform into an article or two. Will they make the Top 10 Papers of 2017, or possibly even win? We certainly hope so!

This month in Anaesthesia sees yet another possible victory for sugammadex as compared with neostigmine for the reversal of rocuronium-induced neuromuscular blockade. Laryngeal microsurgery is an example of a short surgical procedure where surgeons request deep neuromuscular block yet complete reversal prior to emergence and extubation. (Of course, trans-nasal rapid insufflation ventilatory exchange [THRIVE] is an exciting alternative these days – but that debate is for another time.) This presents an obvious dilemma for the anaesthetist, as intubating, operating and extubating conditions are traded off against emergence and recovery time. Choi et al. randomly allocated 44 patients to receive either high-dose rocuronium (0.9 mg.kg-1) with sugammadex reversal (4 mg.kg-1) or low-dose rocuronium (0.45 mg.kg-1) with neostigmine reversal (50 μg.kg-1 with 10 μg.kg-1‑ glycopyrrolate) for patients having laryngeal microsurgery. Unsurprisingly, onset time, level of block, operating conditions and recovery time (2.1 vs 9.9 minutes) were all superior in the sugammadex group. The clinical efficacy and versatility of sugammadex is substantial yet its financial cost remains a major barrier preventing widespread use. The insightful accompanying editorial by Bailey asks when it is appropriate to use sugammadex and whether we should be using it more. The general message seems to be that there are certain circumstances where it is most definitely appropriate, but neostigmine is by no means dead……just yet.

The ethics of airway research have been extensively debated in recent issues. This month, Cook et al. provide discourse in relation to ‘consensus on airway research ethics’ (CARE) published in Anaesthesia. The issue seems to be whether or not the consensus guideline is necessary at all and how such research can reflect an increasingly complex workload that includes more ASA 3+ patients with difficult airways. The ultimate question Cook et al. ask is: how generalisable is manikin-based airway research? The authors of the guideline provide a counter opinion in the correspondence section and argue that rather than an all-encompassing mandatory protocol, the CARE guidelines were designed to provide guidance and to promote informed discussion in the field of airway research. What do you think? Send us a letter through our correspondence website!

There are three further airway papers of interest this month, all in relation to paediatric anaesthesia. Firstly, Mihara et al. performed a network meta-analysis* of various types of supraglottic airway device in children (Figure 1).

Figure 1. Network graph for insertion failure at ﬁrst attempt. The size of the blue node represents the number of patients included in studies featuring that device. The thickness of the lines connecting the nodes is proportional to the number of head-to-head randomised controlled trials in each comparison. The numbers next to the connecting line indicate the number of randomised controlled trials. Where a number is absent, there is only one trial reporting that comparison. airQ-SP, self-pressurised air- Q; Ambu-AG, Ambu AuraGain; Ambu-i, Ambu Aura-i; Ambu-o, Ambu AuraOnce; c-LMA, laryngeal mask airway Classic; Cobra, Cobra perilaryngeal airway; f-LMA, ﬂexible laryngeal mask airway; LT, Laryngeal Tube; p-LMA, Proseal laryngeal mask airway; s-LMA, Supreme laryngeal mask airway; SLIPA, Streamlined Liner of the Pharynx Airway; u-LMA, laryngeal mask airway-Unique

They identified 65 trials with 5823 patients assessing 16 different supraglottic airway devices to determine oropharyngeal leak pressures, first attempt success, blood-staining risk and device failure. They reported that LMA®-Proseal and i-gel™ have high oropharyngeal leak pressures and a low risk of insertion trauma, as previously suggested, however the risk of device failure with i-gel™ is somewhat higher. Nevertheless, before translating this study into clinical practice it may be worthwhile reading the accompanying editorial by Nørskov et al. Scientific evidence, important though it is, forms only one piece of the puzzle when choosing whether to adopt a new airway device into clinical practice.

How does the UK fare in terms of anaesthetic research output as compared to other G-20 countries over the last 15 years? As revealed by Ausserer et al., although the absolute number of anaesthesia articles (2564 from the UK in 2011-2015, if you’re wondering) is steadily increasing, there has been a considerable lack of relative growth from many developed countries against a backdrop of an 11 and 9-fold increase for China and India respectively (Figure 2).

Of course, our Canadian cousins published the most articles per million inhabitants, which is testament to their research systems. But is this a cause of concern for the UK, or is it that output, as measured by the quantity of publications, only tells part of the story?

The early withdrawal of treatment for out of hospital cardiac arrest (OOHCA) victims and those with a devastating brain injury is never straightforward as we cannot predict the probability of survival with absolute precision. Yet there is evidence and even an expert consensus-based pathway for OOHCA victims that advises against prognostication during the first 72 hours after return of spontaneous circulation. Manara and Menon present a compelling argument for translating these practices to the care of those patients who have suffered a devastating brain injury. This would offer a number of benefits including the survival of a small number of retrievable patients, permitting families time to come to terms with a catastrophic event, allowing informed withdrawal after an appropriate interval, offering families the opportunity for carefully considered organ donation, and supporting development of the evidence base for clearer prognostication and decision making in the management of patients. As we have seen before, perhaps we need to stop the concept of therapeutic nihilism?

Elsewhere in the October edition there is an interesting comparison of oral chloral hydrate and intranasal dexmedetomidine to facilitate CT scanning in children, an evaluation of the Minto TCI model during cardiopulmonary bypass, an RCT comparing different analgesic approaches for postoperative pain following caesarean section, and the description of a novel approach to thoracic paravertebral block (Figure 3).

The well-documented struggles trainees have suffered recently are compounded by training requirements and clinical workload. So how do the pressures of modern day training affect physical, psychological and social well-being? McClelland et al. looked to answer this question by conducting a national survey of trainees and assessing the impact of night shifts on fatigue. Over half of all trainee anaesthetists responded, with an even spread of training grades. After finishing a night shift, nearly half of the respondents needed to drive on the motorway to get home, and nearly a fifth travelled for more than 60 minutes. This is compounded by the fact that 84.2% of respondents claimed to be too tired to drive home after a night shift, and more than half having experienced either an accident or a near miss (including falling asleep at the wheel) on their post-nights homeward journey. Less than a third of trainees were aware of rest facilities following night shifts, and if they were available, they could cost up to £65 a shift. Night shifts commonly led to sleep disturbance and the use of substances such as caffeine to mitigate the adverse effects of their fatigue. Finally, the study authors found that personal relationships, physical health, psychological well-being, the ability to do the job and the ability to manage exam revision and projects were all negatively affected by fatigue in more than half of respondents. All in all, McClelland et al. have reported highly concerning adverse effects of the working patterns of anaesthesia trainees.

Michael Farquhar has followed this up with a telling editorial, questioning the ‘hero attitude’ that trainees have been encouraged to develop, and describing the measures his institution and specialty have taken to mitigate the worrying results reported by McClelland et al. These include breaks that are not voluntary, mandatory training in sleep hygiene, and changing culture to accept that self-care is not ‘an optional luxury.’ We should no longer believe that we as doctors can fool physiology, particularly at a time when morale is plummeting, and burnout is on the rise.

In a very different study, Suehana Rahman et al. present a much-needed review of the literature pertaining to patient medical alert identification (ID) tools, something that seems to have slipped under the regulation radar thus far. Medical ID tools can be in the form of jewellery, body art such as tattoos, personal devices, medical ID cards, or other forms such as key rings or bag tags (Fig. 1).

They could present a range of material, including allergy status, information of medical conditions the ID carrier suffers from, pharmacotherapy, and contact details of next of kin. The authors conducted a systematic review of medical databases as well as a Google search, and found four reports of adverse events due to medical alert jewellery, and 32 online vendors of medical alert jewellery, with no evidence of any standards and minimal involvement of physicians. There was no evidence reported that medical IDs ‘work’ or are even safe. With little guidance available, the authors proposed four principles:

Medical IDs should be substantiated by messages conveyed by patients

In unconscious patients, healthcare workers should not conduct ‘disproportionate searches’ for medical IDs

If medical IDs are discovered in unconscious patients, staff should interpret the information rationally and proportionately

Conscious patients should convey all relevant information directly and not rely on the information in IDs alone

Could these proposals be the start of a new era of international standardisation of medical alert IDs?

Contrary to this scarcely-researched question, Stens et al. reported another interesting study, fuelling the ongoing debate regarding the value of intra-operative cardiac output monitoring on perioperative outcomes. They assessed the addition of pulse pressure variation and cardiac index to arterial blood pressure monitoring via the non-invasive ccNexfin device in patients undergoing general surgery. This multicentre, double-blinded trial randomised 244 patients to either be monitored with just continuous arterial pressure, or adding pulse pressure variation and cardiac index monitoring to standard arterial pressure monitoring and managing fluid therapy according to a specified algorithm. They found that there was no difference in 30-day complications, total fluid and blood products infused, fluid loss and blood loss, or return to mobility. Notably, fewer patients in the control group needed vasopressors. So, does this add further fuel to the fire against goal-directed therapy with cardiac output monitoring? Or does this simply suggest that the Nexfin device does not reliably contribute to improved patient outcomes? Only time will tell.

Another question of time relates to pre-operative fasting guidelines. We mandate a six-hour fast for solids and two hours for clear fluids, but what is really going on in the stomach in emergency patients after this duration of time? Dupont et al. performed gastric ultrasound assessment, determining the volume of the gastric antrum, in 263 patients who were starved for > 6 h and having emergency surgery (Fig. 2).

Figure 2. The distribution of gastric volume estimated for 263 participants before unplanned surgery, after at least six hours of fasting

They found that more than a third of patients had volumes consistent with unstarved stomachs, and the size of the antrum was associated with BMI and the pre-operative consumption of morphine. Moreover, one patient in their cohort suffered from pulmonary aspiration, yet this patient did not have a gastric antrum that suggested a full stomach. The data presented by Dupont et al. suggests that the duration of pre-operative starvation may not be related to gastric antral area, and thus volume, in emergency surgery – so what does this mean for aspiration risk without rapid sequence induction in all emergency surgery patients?

On the subject of food, there is plenty of food for thought from novel, thought-provoking and practice-changing papers published in the September edition of Anaesthesia. The dynamic research group working with the NIAA and The James Lind Alliance Priority Setting Partnership explored the difference in anaesthesia and critical care research priorities between clinicians, carers and patients. Despite all groups prioritising patient safety, they found a discrepancy between patients and clinicians – the former favouring patient experience while the latter favouring clinical effectiveness. A surprising result? Perhaps not. However, in another paper published this month, Berning et al. surveyed nearly 500 patients to compare the effect of quality of recovery from surgery on patient satisfaction and they found little correlation. So how is patient satisfaction, experience, quality of recovery and clinical effectiveness all linked, and what is most important? Expect a flurry of research trying to answer this question in the coming years!

Also in the September edition, Chen et al. reported an increased success rate of double-lumen endobronchial intubation using a novel wireless videostylet, the Disposascope® versus conventional intubation (Fig. 3), Shah et al. found that psoas muscle mass is associated with mortality following elective AAA repair, and Pillai et al. discovered that Luer and non-Luer spinal needles are equally as strong! All this and much more in one of the most diverse editions of Anaesthesia this year – eat, drink and sleep well!

Figure 3. The Disposascope® in a pre-shaped double-lumen tube with the wireless monitor

Other than the ground-breaking results of John Carlisle that we have recently discussed, this latest issue of the Journal gives us food for thought in our management of acute pain. Pritchard et al present a unique cost-effectiveness analysis of using patient-controlled analgesia (PCA) vs standard care in patients admitted from the emergency department for the management of acute traumatic or non-traumatic abdominal pain. They assessed hourly visual analogue scale (VAS) pain scores for 12 hours in 20 patients meeting inclusion criteria, and determined the hourly rates patients were in moderate to severe pain (VAS ≥45). Cost-effectiveness was quantified by determining the additional cost per hour that moderate to severe pain was avoided with PCA rather than standard practice. As expected, overall costs were higher in the PCA groups but did this translate in to additional cost-effectiveness benefits? It turns out, an additional £24.77 and £15.17 per hour were incurred to avoid moderate to severe pain in the PCA group in traumatic and non-traumatic abdominal pain groups respectively. This was spent on a range of additional tasks and equipment that was not seen in the standard care group (Figure 1).

Figure 1. Time and staff costs for patient-controlled analgesia and standard care groups per participant during the 12-h study period. Values are mean (SD)

The question of whether these costs represent value for money, and a more philosophical approach to this evaluation was published in an accompanying editorial by Doleman and Smith. They argue that choosing a cut off VAS of ≥45 arbitrarily puts patients with a VAS of 44 and 46 in separate severity of pain categories, which might invalidate the economic evaluation. Additionally, they followed up on the baseline data reported by Pritchard et al and found that the usual care group had higher pain scores than the PCA group. Moreover, Doleman and Smith ask an invaluable question: is the choice of outcome measure (VAS) looked at really that important? If not, which outcomes are actually important? Despite some interesting criticism of the study, I think it is safe to say that the unique methodology taken by Pritchard et al is worthy of reviewing and applying in similar studies in the future.

Speaking of novel pain management research, Lyngeraa et al report a randomised, double-blind pilot study of a novel ‘suture-method’ peripheral nerve catheter. It consists of a curved suture needle, a needle hub, and a catheter that can be placed under ultrasound-guidance in close proximity to a target nerve, with the distal end of the catheter emerging at a distal site (Figure 2).

Figure 2. The suture-method catheter. Left: The suture-catheter device. N, needle; H, hub; and C, catheter. Right: The suture-method catheter during insertion. The needle has been inserted past the nerve to exit the skin on the other side of the nerve

The idea behind this technique is that catheters might be easier to insert in the appropriate position and should displace less than traditionally sited catheters. Sixteen volunteers had bilateral ultrasound-guided sciatic nerve catheters placed with the suture-method catheter system, and were randomised to receive either local anaesthetic or saline in each leg. They reported a 94% success rate in the initial catheter placement, but only three-quarters were still effective after vigorous physical exercise. The study authors argue that the novel suture-needle design is as effective as other techniques, and speculate that it might be more secure due to the double skin penetration anchoring, whilst reducing local anaesthetic leakage as the catheter is the same diameter as the placement needle. They also suggest that it might be easier to insert and see on ultrasound than traditional catheter techniques.

Of course, they have little data to truly support their claims of superiority of the suture-needle catheter, argues Fredrickson. This design necessitates a more invasive insertion, catheter placement tangential to nerves, extra steps to catheter insertion, and technical challenges to inserting a curved needle, all of which are significant drawbacks of this design. Additionally, Fredrickson’s group often insert ambulatory catheters that patients can remove themselves at home, a strategy that would be impossible to achieve with the suture-needle system as it needs medical expertise to remove. Traditional catheter techniques, argues Fredrickson, are currently superior and should be increasingly used in clinical practice. Of course, some experts believe that there is no role for catheters at all in management of perioperative pain – but that is a discussion for a different day.

Our next pain study in this issue of the Journal comes from Holmberg et al, who compared the effectiveness of a pre-operative vs post-operative analgesic infraclavicular brachial plexus block in 52 patients having radial fracture fixation surgery. Patients were randomised, and the time to first rescue analgesia after emergence from general anaesthesia, as well as pain scores, rescue analgesia, and plasma stress markers. Surprisingly, patients who had the pre-operative blocks requested rescue analgesia on average more than three-hours later than those who had the post-operative blocks, and their absence of sensory and motor function lasted an hour longer (Figure 3).

Moreover, they had lower pain scores up to four hours after surgery, and lower analgesic consumption in the first post-operative week. However, there was no difference in ‘strong pain’ after block resolution, stress markers, and chronic pain between pre-operative and post-operative block groups. Overall, Holmberg et al have elegantly demonstrated the potential for pre-emptive regional analgesia to attenuate short-term pain.

Our final pain study was an interesting Cochrane systematic review assessing the analgesic efficacy of remifentanil patient-controlled analgesia (PCA) vs other parenteral analgesic strategies in labour. Jelting et al sought relevant randomised, controlled, and cluster-randomised trials reporting patient satisfaction with pain relief and adverse events. Twenty studies informed their analysis, although the outcomes they sought were poorly reported. When compared to other parenteral opioids, remifentanil PCA demonstrated superior satisfaction, but inferior patient satisfaction to epidural analgesia. There was not much to show for the difference in respiratory depression, nor low Apgar scores between remifentanil PCA and epidural analgesia. However, the authors attributed low or very low quality of evidence to most of the reported results. Does this tell us that we just don’t know yet?

We often assume what we were always taught must always be true. But what if it’s not? What if we make efforts to go beyond dogma and do things differently; understand things differently? July’s issue of Anaesthesia might just encourage readers to do that by publishing work on anaemia, laryngoscopy grading, and more.

Haemoglobin is the vehicle that helps to keep us alive, and surgery is an insult that may remove that vehicle. But do we know enough about pre-operative anaemia and iron deficiency to optimise the vehicle? In this month’s issue of Anaesthesia, Muñoz and colleagues presented a retrospective cohort study of five centres in Spain addressing precisely this question. They assessed data from more than 3000 patients undergoing a range of surgical procedures in which the underlying pathology predisposes to anaemia, has an expected risk of > 500 ml blood loss, and/or has a > 10% transfusion risk. They found that one third of patients were anaemic (Hb < 130 g.l-1), of which two-thirds had either iron deficiency or iron sequestration, and, perhaps unsurprisingly, two thirds of anaemic patients were women. Notably, 62% of anaemic patients had absolute iron deficiency, but half of non-anaemic patients were iron deficient or had low iron stores. They took this information and incorporated the recently published game-changing international consensus statement on anaemia management to suggest management for different scenarios pertaining to iron deficiency (Fig. 1).

This data was accompanied by a thought-provoking editorial by Butcher et al, who looked at the findings from a different perspective. Butcher et al. suggest that, as women generally have smaller circulating blood volumes than men, the same peri-operative blood loss would have a significantly larger effect on the former than the latter. Compounding this, we have long accepted that anaemia in women is defined by a lower Hb than that for men, and therefore females are more likely to require transfusion. This is a curious paradox, one which has received little consideration in the past. However, Butcher and colleagues point to Muñoz’s data as a demonstration that, if target Hb concentrations are the same between men and women, the latter are far more likely to be anaemic. It is imperative, therefore, that we readjust our age-old targets, and consider changing the arbitrary cut-offs of to 130 g.l-1, irrespective of sex. This novel thinking is likely to drive a significant amount of research in the future, and could perhaps increase the safety of patient management, no matter the gender.

O’Loughlin et al have assessed a question that many haven’t asked: what scoring system should to describe glottic visualisation at videolaryngoscopy? The authors compared the age-old Cormack and Lehane score (published in Anaesthesia just 35 years ago), the percentage of glottic opening (POGO) score, and the authors’ very own Fremantle score. As a quick reminder, the POGO score is an estimate of the percentage of the glottic inlet that is seen on laryngoscopy, and the Freemantle score is the three-component composite describing the view, the ease of intubation and the device use for intubation. The authors showed 20 videolaryngoscopic intubation videos to 74 critical care physicians, and compared accuracy with an expert panel assessment, as well as assessing intra- and inter-rater reliability. They found that the POGO and Fremantle score are superior to the Cormack and Lehane score in the outcomes assessed. However, O’Loughlin et al go one step further and suggest that, because their Freemantle score provides additional information about the ease of intubation, this should be the go-to scoring system. Of course, few anaesthetists in the UK apply this scoring system, and ultimately the reason to describe the view at laryngoscopy is for communication. The next question should be: does the Fremantle score improve communication enough to drop the tried and tested Cormak and Lehane score?

This issue of the Journal next takes us to a simple, yet novel method for determining the location of epidural needle placement using continues pressure wave-form monitoring. By attaching extension tubing attached to a pressure transducer to epidural needles, pulsatile waveforms synchronised with heart rate represent epidural placement (fig. 2). 93% of patients who had effective epidural block also had a clear epidural pressure waveform on transduction. This technique thus provides, in the authors words, a ‘simple adjunct to loss-of-resistance for identification of needle placement.’ Of course, can you imagine the challenge in routinely locating a transducer set, appropriate monitor, whilst meeting 30 minute to attendance for epidural placement limit that many departments work towards? Neither can McKendry and Muchatuta, who question the necessity for this technique in the obstetric environment, and suggest that not only should other techniques be explored, but one should always consider that problems with regional anaesthesia techniques might be addressed by ‘looking for the cause on the proximal end of the needle.’ So let’s work out how best to improve our technique!

Novelty is abound, and Leong et al have presented a vital signs-controlled remifentanil PCA technique. By programming a PCA device to act based on feedback from vital signs, the authors demonstrated a reduction in adverse events. Scholten et al published an exciting systematic review of novel techniques to assist with needle tip identification during ultrasound-guided procedures. They summarise the data on needle guides (including lasers!), needle tip design, 3D and 4D ultrasound, magnetism, robots and more. The challenges of regional anaesthesia might be overcome by the plethora of technological advances. Feng, Liao and Huang demonstrated that internal iliac artery balloon catheters might not be as effective for placenta accreta than we once thought; Flubacher et al demonstrated what we probably know about the efficacy of ondansetron as an anti-emetic; and Brix and colleagues found that day surgery does not always mean single day care episodes.

That was our whistlestop tour of the July issue of the Journal, but much more can be found between the covers that is sure to excite, entice and enlighten all who read it!